CLEVELAND, Ohio — In a bright and colorful preschool classroom in East Cleveland, 18 children keep their two teachers on the move.

In one corner of the room, two boys build structures with Legos. Teacher Kim Garrison, 48, helps four children play a memory game with SpongeBob SquarePants cards, and a gaggle of students build houses, cakes and pizzas with magnetic tiles, running over frequently to present them to Garrison.

At a low table with five diminutive chairs, teacher Robin Puchalksi helps a small group of girls cut out and paste pictures of food onto colored construction paper.

“Now, is that a healthy food?” she asks, pointing to a picture of green beans.

“Yes,” the girls tell her, nodding enthusiastically.

After most of the girls have finished their collages, Puchalski remains at the table with one, who is moving a little slower, having a harder time cutting her paper, and has not been as talkative during the exercise.

One-on-one time and individualized lesson plans can be difficult to accommodate in a full class of high-energy preschoolers, but it’s one of the things that distinguish “high quality” preschool programs, like the one at the George L. Forbes Early Learning Center, from others.

And while high quality preschool has been shown to help particularly children who have cognitive or developmental deficits related to trauma or exposure to poverty, recent research by Case Western Reserve University and Cuyahoga County’s early childhood initiative Invest in Children shows that even long exposure is not enough to help kids who have lead poisoning catch up with their peers.

Looking at children who attended high quality preschool for at least 18 months (a “high dose”) among more than 35,000 Cleveland and 11 inner-ring suburban kindergartners, the researchers found that children with a history of lead exposure above the threshold of concern set by the Centers for Disease Control and Prevention were half as likely as their peers to score “on track” in language and literacy when they reach kindergarten.

The CDC’s threshold, 5 micrograms of lead per deciliter of blood, is the level at which public health actions should be taken, including education of parents on how to minimize exposure, follow-up testing, and routine dietary and developmental monitoring.

The difference in test performance between children with lead poisoning and their peers couldn’t be explained by mitigating factors such as birth weight, premature birth, family income, maltreatment and a mother’s education level, among others.

“It’s not exactly the news we wanted, obviously,” Rebekah Dorman, Invest in Children’s director, told The Plain Dealer when presenting the results. “We would have loved to see that you get [children with lead exposure] into high-quality [preschool] or into Universal Pre-K and it’s mitigating everything, but it’s a lot to ask of preschool.”

The researchers reported another disappointing finding: Only one in five Medicaid-eligible children entering kindergarten in Cleveland public schools from 2011 to 2016 were screened for lead poisoning at both ages 1 and 2 years old, as recommended by federal guidelines.

While most (90 percent) have had at least one screening test by the age of kindergarten entry, a failure to test at an early age can mask the cumulative effect of lead exposure over a lifetime, the researchers said.

Medicaid guidelines for screening for lead poisoning recommend a test at both ages 1 and 2 years old.

“Children might show up at kindergarten and no longer have lead in their blood if they’re tested [then], but that doesn’t mean that they didn’t have a time in their lives when they were exposed to lead,” said Beth Anthony, senior research associate at Case’s Center on Urban Poverty and Community Development. “That damage is still really important to think about in terms of how the kindergarten teacher and the school system is going to respond, or how the community at large can respond.”

Low screening rates problematic

In Garrison and Puchalski’s class, no children had high lead-screening results this year, the teachers said. They know because all students at the center have to have a lead test upon entry to the school, and the information is shared with teachers and the site’s health coordinator to help inform and customize the learning experience.

The school also hosts an annual visit from a Cleveland Clinic mobile unit, which offers free lead screens to all the students.

It’s possible that students were exposed to lead before entering preschool, however, as lead can leave the blood after about a month if there is no ongoing exposure. The toxin remains in the brain for up to two years. About 22 percent of children screened for lead in East Cleveland in 2016 had blood levels above the CDC’s threshold of concern.

But children attending the George Forbes center seem to be in the minority citywide when it comes to adequate and timely screening for lead poisoning.

Only half of the 18,000 children in CWRU’s sample who were Medicaid-eligible were tested for lead exposure at age 1, the first recommended screening. Even fewer, about 35 percent, were tested at age 2 as recommended. Of those who got a screening by 2 years old, more than one-third had blood lead levels above the CDC threshold of 5 micrograms per deciliter.

No level of lead is considered safe for children, and national research has found that even small amounts can damage developing brains, leading to lower IQs, increased impulsivity, and heart and kidney problems later in life.

While the research team can’t be sure why children aren’t being screened on schedule, they suspect it has less to do with doctors informing parents of the need, and more with difficulty in getting the child to the screening.

“If you’ve ever gone to a lab recently, especially if you’re with a toddler, even if you get there there’s often a wait,” said Dorman. Parents with small children may find it difficult to make the extra trip or may be unable to stay as long as needed for the test, she said. “Those are things we want to look at, how to make the screening easier.”

There are local efforts underway to increase the screening rate, though they mostly involve older school-age children. The Partners in Health lead screening project, a collaborative of the city, Cleveland Municipal School District and students from the Frances Payne Bolton School of Nursing at Case Western Reserve University, began testing children ages 3- to 5-years-old during the 2016-2017 school year. Their preliminary results showed high levels of the toxin in 11 percent of kids tested at four area elementary schools.

The partnership will continue testing this year, has a goal of screening children at 12 more Cleveland schools, and is “actively seeking additional funding” to reach its goal of screening half the city's 68 K-8 schools by the end of next year.

The project's findings are in line with state health department data released for lead levels among Cleveland children: about 12 percent of city children under 6 who were screened for lead in 2016 and 2017 had a level of the toxin in their blood that required action. This is about four times the national average.

CWRU and Invest in Children’s research underscores the importance of adequate screening at an early age, to catch and eliminate exposure to lead early on, and to identify children in need of developmental and learning support even before they reach preschool.

Of course, said Dorman, the most important message from the team’s data is that the only sure way to protect children from the damaging and long-lasting effects of lead is to prevent exposure.

“It’s hard to fix once it happens,” Dorman said.

What can be done

The children studied in the research sample all attended at least 18 months of high-quality preschool, distinguished in Ohio by a three-star or higher rating by the state’s “Step Up to Quality” five-star rating system. The rating is based on achieving standards in learning and development, administrative and leadership practices, staff qualifications and professional development, and family and community partnerships.

About 1,400 children in the sample of more than 35,000 children received this “high dose” of high quality preschool, based on childcare voucher records, enrollment in the county’s Universal Pre-Kindergarten (UPK) programs or preschool attendance in the 12 school districts with records in CWRU’s ChildHood Integrated Longitudinal Data (CHILD) system. Of these, 215 children, or 15 percent, had lead levels above the CDC’s threshold of concern.

A subsequent analysis of this group of children with lead poisoning who received a high dose of high-quality preschool revealed some differences between kids who were falling behind and those who weren’t, despite their exposure. The 160 kids with lead poisoning who were “not on track” in literacy and language were more likely to have been born too early or too small, and to have experienced prolonged periods of poverty, when compared with the 55 children with lead poisoning who did score “on track.”

The researchers could not include children who attended low-quality preschool, children who attended preschool outside Cleveland or the 11 inner-ring suburbs, or those children who didn’t attend preschool at all in the analysis, because there is no way to track these children within the database.

“We all guess that if you got low-quality preschool, or nothing, that the results might look even worse,” said Dorman. “But we don’t know that for sure yet.”

The findings reinforce previous work by the CWRU/Invest in Children team, who used the CHILD database to track how the children fared.

In 2015, the same team examined the effect of lead poisoning on kids enrolled in UPK. In that study, children were put into three groups: those with no record of a lead test; children who had positive lead levels below 5 micrograms per deciliter, the current threshold that triggers monitoring; and children with lead levels above 5.

All of the kids with no record of a lead test did much better on every evaluation than the children with a history of lead in their blood. Children with more lead in their blood did the worst: While they made gains in UPK, they left preschool knowing less about basic concepts like letters, numbers, sizes and shapes than their peers knew when they entered UPK.

In a 2012 study commissioned by the group, Cleveland children who scored the lowest on a school readiness assessment were twice as likely to be lead poisoned than kids who scored higher.

Helping those exposed to lead

What can be done to help children exposed to lead is a question the research team is struggling to answer.

Preschool teachers, staff and parents in Cuyahoga County can request free technical assistance and training to help accommodate the learning needs of children with developmental, health, physical, social-emotional or behavioral challenges from an agency called Starting Point (See list of resources below or click here).

These are the resources many preschools call on for help when children arrive at school with a history of lead poisoning.

“Starting Point has been a really great partner with us…with the trainings that we have here,” said George Forbes Pre-K teacher Garrison. “We use it a lot.”

Children under the age of 3 in Ohio are also eligible for coordinated services through the state’s Department of Developmental Disabilities’ (DODD) Early Intervention, or EI, program if the child has a blood lead level above 5 micrograms per deciliter and a diagnosed disability, or if a doctor believes a lead-poisoned child may face such a disability and requests the services. In at least 15 other states, eligibility for EI services is automatic for some children with high lead levels. CWRU’s Schubert Center for Child Studies as well as members of the health care, legal and child-advocacy community recently recommended to the Ohio DODD that the state change its eligibility policy to also be automatic for any child with a lead level above 5.

Garrison, who has been teaching preschool for 27 years, said she used to see a lot more lead poisoning among her students in the early 2000s when the rate of poisoning was four times as high in the city as it is today.

She thinks a lot can be done for children with lead poisoning, even in Pre-K, such as one-on-one instruction addressing the child’s deficits, if they are identified. “I feel personally that if a child does have high lead, if you address the issue when it's there and you show more concern and you show more involvement with the families, the families are going to be more on top of it.”

Still, it’s clear that preventing exposure, or intervening even earlier than preschool, is likely the most effective way to help kids flourish in school, according to the research team.

The team would like to use the CHILD system, which includes data from 1989 to the present from 35 administrative systems on more than 640,000 area children, to see if children exposed to lead who had early interventions, such as newborn home-visiting, fare better when they get to school.

“We don’t want to abandon the idea of helping these children after exposure, but we don’t have anything right now to tell us exactly how to do that,” Dorman said. “I think it’s a challenge for us to think about what else can happen to help the kids.”